What are the key Utilization Management metrics that you monitor and report on a regular basis?

1 Admission Rate

Admission rate is the number of inpatient admissions per 1,000 members or enrollees in a health plan or program. It reflects the demand and utilization of hospital services, and it can vary by diagnosis, provider, region, and population. Admission rate is a key indicator of the appropriateness and necessity of inpatient care, and it can help you identify opportunities for reducing avoidable or preventable hospitalizations, improving care coordination, and enhancing patient satisfaction.

2 Length of Stay

Length of stay (LOS) is the number of days that a patient stays in a hospital or other facility for a given episode of care. It measures the intensity and duration of inpatient services, and it can affect the cost, quality, and outcome of care. LOS is influenced by many factors, such as the patient's condition, the provider's practice patterns, the facility's resources and policies, and the discharge planning process. LOS is a key metric for assessing the efficiency and effectiveness of inpatient care, and it can help you optimize the use of resources, reduce complications and readmissions, and improve patient outcomes.

4 Denial Rate

Denial rate is the percentage of UM requests or claims that are denied or rejected by a payer or reviewer for various reasons, such as lack of medical necessity, insufficient documentation, or non-compliance with policies or guidelines. It measures the alignment and agreement between the providers and the payers or reviewers on the appropriateness and validity of health care services and payments. Denial rate is a key metric for monitoring and managing the UM process, and it can help you reduce administrative burden and waste, increase transparency and communication, and resolve disputes and appeals.

5 Utilization Rate

Utilization rate is the number of specific health care services or procedures per 1,000 members or enrollees in a health plan or program. It reflects the frequency and variation of health care utilization, and it can vary by type, level, setting, and provider of care. Utilization rate is a key metric for comparing and benchmarking the utilization patterns and trends among different populations, regions, and providers, and it can help you identify and address the drivers and barriers of health care utilization, such as access, quality, cost, and preference.

6 Satisfaction Rate

Satisfaction rate is the percentage of patients, providers, or payers who express satisfaction or dissatisfaction with the UM process, outcomes, or experience. It measures the perception and feedback of the UM stakeholders, and it can affect the trust, collaboration, and loyalty among them. Satisfaction rate is a key metric for measuring and improving the customer service and value of UM, and it can help you enhance the responsiveness, timeliness, and fairness of UM decisions, actions, and communications.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?